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SAN JOAQUIN LOCAL HEALTH UlSI k1Cl <br />.�--F®ROF ICE USE: 1601 E. Hazelton 'Ave. , Stockton, CA 95205 Permit No.�� �/ —�,d <br /> Telephone.; (209) 466-6781 <br /> APPLICATION .FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit -Ex - ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application ' is hereby made to the San Joaquin .Local Health District for a permit to construct <br /> and/or instal! the work herein described.. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and tLe R les and Regulations of the San Joaquin Local- Health <br /> District: G G <br /> EXACT STREET ADDRESS CITY/TOWN } <br /> Owner's Name Phone <br /> Address -PLZ / City <br /> Contractor' s Name Li cense# �y 7i1ione� <br /> IS CERTIFICATE OF WORKMAN'S 1AMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIRRI PUMP REPLACEMENT ❑ s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> )C Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - -- 6 %4 ,..� H.P. <br /> PUMP REPLACEMENT: FIState Work Done <br /> PUMP REPAIR: State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter �� Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State, Laws , and Rules and. Regulations of the San Joaquin Local . <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Warkman 's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPE TION P34R TO GROUTING AND A FINAL INSPECTION. t <br /> SIGNS ITLE: TE: <br /> RAW PLOT PLA1q ON REVERSE SIDE _ <br /> FOR DEPARTMENT USE ONL O.. Auf;r, <br /> PHASE I <br /> APPLICATION ACCEPTED BY 5'4 01 DA �- <br /> ADDITIONAL COMMENTS: - ; Wrn,� <br /> PHASE II GROUT INSPECTION PHASE III FINV INSPECTION <br /> INSPECTION BY DATE INSPE ION BY DATE y <br />